Objective To determine if ultrasound (US) localization is equivalent to surface landmark localization to identify botulinum toxin (Btx) injection targets for forearm muscle spasticity. Design Observational Setting Outpatient spasticity clinic in a tertiary care center. Subjects 18 patients with upper extremity flexor spasticity interfering with function were included. Individuals with severe fixed contractures or traumatic injury of the involved forearm were excluded. Methods Flexor pollicis longus (FPL), flexor carpi radialis (FCR), pronator teres (PT) and flexor digitorum superficialis (FDS) were identified by 2 separate localization techniques: the method of Delagi and Perotto for FCR, PT and FPL, and a surface landmark technique by Bickerton to identify the 4 muscle bellies of FDS. Proximodistal and lateral (radial) coordinates were recorded relative to a landmark line (LL) from the medial epicondyle to pisiform bone and percentage of LL distance was calculated. After surface measurements were collected, the best point for injection was determined using real time US with a 12 MHz linear transducer. US measurements were recorded using the same LL system. Results Localization techniques were compared using the Wilcoxon Signed Ranks Test. One-sample t-tests compared surface mapped lateral coordinates to ultrasound derived lateral coordinates with controls for multiple testing. Significant differences were observed between surface and ultrasound proximodistal and lateral coordinates for several flexor muscles. Conclusions Ultrasound should be considered as an adjunct for localization in patients with upper limb spasticity. US can improve accuracy of toxin placement and help to avoid injection into vascular and nerve structures.

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People with spinal cord injury (SCI) are predisposed to pressure ulcers (PU). PU remain a significant burden in cost of care and quality of life despite improved mechanistic understanding and advanced interventions. An agent-based model (ABM) of ischemia/reperfusion-induced inflammation and PU (the PUABM) was created, calibrated to serial images of post-SCI PU, and used to investigate potential treatments in silico. Tissue-level features of the PUABM recapitulated visual patterns of ulcer formation in individuals with SCI. These morphological features, along with simulated cell counts and mediator concentrations, suggested that the influence of inflammatory dynamics caused simulations to be committed to “better” vs. “worse” outcomes by 4 days of simulated time and prior to ulcer formation. Sensitivity analysis of model parameters suggested that increasing oxygen availability would reduce PU incidence. Using the PUABM, in silico trials of anti-inflammatory treatments such as corticosteroids and a neutralizing antibody targeted at Damage-Associated Molecular Pattern molecules (DAMPs) suggested that, at best, early application at a sufficiently high dose could attenuate local inflammation and reduce pressure-associated tissue damage, but could not reduce PU incidence. The PUABM thus shows promise as an adjunct for mechanistic understanding, diagnosis, and design of therapies in the setting of PU.

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